Comminuted fractures – produce several breaks of the bone, producing splinters and fragments.

Greenstick fractures – break one side of a bone and bend the other.

Spiral (torsion) fractures – involve a fracture twisting around the shaft of the bone.

Transverse fractures – occur straight across the bone.

Oblique fractures – occur at an angle across the bone (less than a transverse)

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Risk Factors

From crushing force or direct blow

Sudden twisting motion; persons with osteoporosis are at a particular risk

Extremely forceful muscle contraction can cause fractures

Pathological fractures result from a weakness in bone tissue, which may be caused by neoplasm or a malignant growth

Pathophysiology

Fracture occurs when stress placed on a bone exceeds the bone’s ability to absorb it.

Stages of normal fracture healing include:

Inflammation

Cellular proliferation

Callus formation

Callus ossification

Mature one remodeling

Potential complications of fracture include:

Life-threatening systemic fat embolus, which most commonly develops within 24 to 72 hours after fracture.

Compartment syndrome, which is a condition involving increased pressure and constriction of nerves and vessels within an atomic compartment.

Nonunion of the fracture side

Arterial damage during treatment

Infection and possibly sepsis

Hemorrhage, possibly leading to shock

Assessment/Clinical Manifestations/Signs And Symptoms

Pain

Edema

Tenderness

Abnormal movement and crepitus

Loss of function

Ecchymoses

Visible deformity

Paresthesias and other sensory abnormalities

Laboratory and diagnostic study findings

Radiographs and other imaging studies may identify the site and type of fracture.

Medical Management

The principles of fracture treatment include reduction, immobilization and regaining of normal function and strength through rehabilitation.

The fracture is reduced “setting” the bone using a closed method (manipulation and manual traction (e.g. splint or cast) or an open method (surgical placement of internal fixation devices like pins, wires, screws, plates and nails) to restore the fracture fragments to anatomic alignment and rotation. The specific method depends on the nature of the fracture.

After the fracture has been reduced, immobilization holds the bone in correct position and alignment until union occurs. Immobilization is accomplished by external or internal fixation.

Function is maintained and restored by controlling swelling by elevating the injured extremity and applying ice as prescribed.

Restlessness, anxiety, and discomfort are controlled using a variety of approaches (e.g. reassurance, position changes, pain relief strategies, including analgesic agents).

Isometric and muscle-setting exercises are done to minimize disuse atrophy and to promote circulation.

With internal fixation, the surgeon determines the amount of movement and weight-bearing stress the extremity can withstand and prescribed the level of activity.

Administer prescribed medications, which may include opioid or nonopioid analgesics and prophylactic antibiotics for an open fracture.

Prevent and manage potential complications.

Observe for symptoms of life-threatening fat embolus, which may include personality change, restlessness, dyspnea, crackles, white sputum, and petechaie over the chest and buccal membranes. Assist with respiratory support, which must be instituted early.

Secure a bedboard under the mattress or place patient on orthopedic bed.

Rationale: Soft or sagging mattress may deform a wet (green) plaster cast, crack a dry cast, or interfere with pull of traction.

Support fracture site with pillows or folded blankets. Maintain neutral position of affected part with sandbags, splints, trochanter roll, footboard.

Rationale: Prevents unnecessary movement and disruption of alignment. Proper placement of pillows also can prevent pressure deformities in the drying cast.

Use sufficient personnel for turning. Avoid using abduction bar for turning patient with spica cast.

Rationale: Hip, body or multiple casts can be extremely heavy and cumbersome. Failure to properly support limbs in casts may cause the cast to break.

Observe and evaluate splinted extremity for resolution of edema.

Rationale: Coaptation splint (Jones-Sugar tong) may be used to provide immobilization of fracture while excessive tissue swelling is present. As edema subsides, readjustment of splint or application of plaster or fiberglass cast may be required for continued alignment of fracture.

Maintain position or integrity of traction.

Rationale: Traction permits pull on the long axis of the fractured bone and overcomes muscle tension or shortening to facilitate alignment and union. Skeletal traction (pins, wires, tongs) permits use of greater weight for traction pull than can be applied to skin tissues.

Ascertain that all clamps are functional. Lubricate pulleys and check ropes for fraying. Secure and wrap knots with adhesive tape.

Review restrictions imposed by therapy such as not bending at waist and sitting up with Buck traction or not turning below the waist with Russell traction.

Rationale: Maintains integrity of pull of traction.

Assess integrity of external fixation device.

Rationale: Hoffman traction provides stabilization and rigid support for fractured bone without use of ropes, pulleys, or weights, thus allowing for greater patient mobility, comfort and facilitating wound care. Loose or excessively tightened clamps or nuts can alter the compression of the frame, causing misalignment.

Review follow-up and serial x-rays.

Rationale: Provides visual evidence of proper alignment or beginning callus formation and healing process to determine level of activity and need for changes in or additional therapy.

Administer alendronate (Fosamax) as indicated.

Rationale: Acts as a specific inhibitor of osteoclast-mediated bone resorption, allowing bone formation to progress at a higher ratio, promoting healing of fractures and decreasing rate of bone turnover in presence of osteoporosis.

Initiate or maintain electrical stimulation if used.

Rationale: May be indicated to promote bone growth in presence of delayed healing or nonunion.

Rationale: Can increase discomfort by enhancing heat production in the drying cast.

Elevate bed covers; keep linens off toes.

Rationale: Maintains body warmth without discomfort due to pressure of bedclothes on affected parts.

Evaluate and document reports of pain or discomfort, noting location and characteristics, including intensity (0–10 scale), relieving and aggravating factors. Note nonverbal pain cues (changes in vital signs, emotions and behavior). Listen to reports of family members or SO regarding patient’s pain.

Rationale: Influences effectiveness of interventions. Many factors, including level of anxiety, may affect perception of pain. Note: Absence of pain expression does not necessarily mean lack of pain.

Rationale: Refocuses attention, promotes sense of control, and may enhance coping abilities in the management of the stress of traumatic injury and pain, which is likely to persist for an extended period.

Rationale: Given to reduce pain or muscle spasms. Studies of ketorolac (Toradol) have proved it to be effective in alleviating bone pain, with longer action and fewer side effects than narcotic agents.

Rationale: Decreased or absent pulse may reflect vascular injury and necessitates immediate medical evaluation of circulatory status. Be aware that occasionally a pulse may be palpated even though circulation is blocked by a soft clot through which pulsations may be felt. In addition, perfusion through larger arteries may continue after increased compartment pressure has collapsed the arteriole or venule circulation in the muscle.

Rationale: Increasing circumference of injured extremity may suggest general tissue swelling or edema but may reflect hemorrhage. Note: A 1-in increase in an adult thigh can equal approximately 1 unit of sequestered blood.

Note reports of pain extreme for type of injury or increasing pain on passive movement of extremity, development of paresthesia, muscle tension or tenderness with erythema, and change in pulse quality distal to injury. Do not elevate extremity. Report symptoms to physician at once.

Rationale: Continued bleeding and edema formation within a muscle enclosed by tight fascia can result in impaired blood flow and ischemic myositis or compartmental syndrome, necessitating emergency interventions to relieve pressure and restore circulation. Note: This condition constitutes a medical emergency and requires immediate intervention.

Rationale: There is an increased potential for thrombophlebitis and pulmonary emboli in patients immobile for several days. Note: The absence of a positive Homans’ sign is not a reliable indicator in many people, especially the elderly because they often have reduced pain sensation.

Rationale: Assists in calculation of blood loss and effectiveness of replacement therapy. Coagulation deficits may occur secondary to major trauma, presence of fat emboli, or anticoagulant therapy.

Administer IV fluids and blood products as needed.

Rationale: Maintains circulating volume, enhancing tissue perfusion.

Split or bivalve cast as needed.

Rationale: May be done on an emergency basis to relieve restriction and improve impaired circulation resulting from compression and edema formation in injured extremity.

Assist with intracompartmental pressures as appropriate.

Rationale: Elevation of pressure (usually to 30 mm Hg or more) indicates need for prompt evaluation and intervention. Note: This is not a widespread diagnostic tool, so special interventions and training may be required.

Rationale: Failure to relieve pressure or correct compartmental syndrome within 4–6 hr of onset can result in severe contractures or loss of function and disfigurement of extremity distal to injury or even necessitate amputation.

Desired Outcomes

Nursing Interventions

Monitor respiratory rate and effort. Note stridor, use of accessory muscles, retractions, development of central cyanosis.

Rationale: Tachypnea, dyspnea, and changes in mentation are early signs of respiratory insufficiency and may be the only indicator of developing pulmonary emboli in the early stage. Remaining signs and symptoms reflect advanced respiratory distress or impending failure.

Encourage use of isometric exercises starting with the unaffected limb.

Rationale: Isometrics contract muscles without bending joints or moving limbs and help maintain muscle strength and mass. Note: These exercises are contraindicated while acute bleeding and edema is present.

Rationale: Useful in maintaining functional position of extremities, hands and feet, and preventing complications (contractures, footdrop).

Place in supine position periodically if possible, when traction is used to stabilize lower limb fractures.

Rationale: Reduces risk of flexion contracture of hip.

Instruct and encourage use of trapeze and “post position” for lower limb fractures.

Rationale: Facilitates movement during hygiene or skin care and linen changes; reduces discomfort of remaining flat in bed. “Post position” involves placing the uninjured foot flat on the bed with the knee bent while grasping the trapeze and lifting the body off the bed.

Provide and assist with mobility by means of wheelchair, walker, crutches, canes as soon as possible. Instruct in safe use of mobility aids.

Rationale: Early mobility reduces complications of bed rest (phlebitis) and promotes healing and normalization of organ function. Learning the correct way to use aids is important to maintain optimal mobility and patient safety.

Provide diet high in proteins, carbohydrates, vitamins, and minerals, limiting protein content until after first bowel movement.

Rationale: In the presence of musculoskeletal injuries, nutrients required for healing are rapidly depleted, often resulting in a weight loss of as much as 20 to 30 lb during skeletal traction. This can have a profound effect on muscle mass, tone, and strength. Note: Protein foods increase contents in small bowel, resulting in gas formation and constipation. Therefore, gastrointestinal (GI) function should be fully restored before protein foods are increased.

Increase the amount of roughage or fiber in the diet. Limit gas-forming foods.

Nursing Interventions

Rationale: Provides information regarding skin circulation and problems that may be caused by application or restriction of cast, splint or traction apparatus, or edema formation that may require further medical intervention.

Massage skin and bony prominences. Keep the bed linens dry and free of wrinkles. Place water pads, other padding under elbows or heels as indicated.

Rationale: Reduces pressure on susceptible areas and risk of abrasions and skin breakdown.

Reposition frequently. Encourage use of trapeze if possible.

Rationale: Lessens constant pressure on same areas and minimizes risk of skin breakdown. Use of trapeze may reduce risk of abrasions to elbows and heels.

Assess position of splint ring of traction device.

Rationale: Improper positioning may cause skin injury or breakdown.

Plaster cast application and skin care:

Cleanse skin with soap and water.

Rationale: Provides a dry, clean area for cast application. Note: Excess powder may cake when it comes in contact with water and perspiration.

Rub gently with alcohol or dust with small amount of a zinc or stearate powder;

Cut a length of stockinette to cover the area and extend several inches beyond the cast;

Rationale: Prevents indentations or flattening over bony prominences and weight-bearing areas (back of heels), which would cause abrasion or tissue trauma. An improperly shaped or dried cast is irritating to the underlying skin and may lead to circulatory impairment.

Use palm of hand to apply, hold, or move cast and support on pillows after application;

Rationale: Uneven plaster is irritating to the skin and may result in abrasions.

Trim excess plaster from edges of cast as soon as casting is completed;

Rationale: Has a drying effect, which toughens the skin. Creams and lotions are not recommended because excessive oils can seal cast perimeter, not allowing the cast to “breathe.” Powders are not recommended because of potential for excessive accumulation inside the cast.

Turn frequently to include the uninvolved side, back, and prone positions (as tolerated) with patient’s feet over the end of the mattress.

Rationale: Minimizes pressure on feet and around cast edges.

Skin traction application and skin care:

Cleanse the skin with warm, soapy water;

Rationale: Reduces level of contaminants on skin.

Apply tincture of benzoin;

Rationale: “Toughens” the skin for application of skin traction.

Apply commercial skin traction tapes (or make some with strips of moleskin or adhesive tape) lengthwise on opposite sides of the affected limb;

Administer medications as indicated:

IV and topical antibiotics;

Rationale: Wide-spectrum antibiotics may be used prophylactically or may be geared toward a specific microorganism.

Tetanus toxoid.

Rationale: Given prophylactically because the possibility of tetanus exists with any open wound. Note: Risk increases when injury or wound(s) occur in “field conditions” (outdoor, rural areas, work environment).

Provide wound or bone irrigations and apply warm or moist soaks as indicated.

Rationale: Local debridement and cleansing of wounds reduces microorganisms and incidence of systemic infection. Continuous antimicrobial drip into bone may be necessary to treat osteomyelitis, especially if blood supply to bone is compromised.

Desired Outcomes

Nursing Interventions

Review pathology, prognosis, and future expectations.

Rationale: Provides knowledge base from which patient can make informed choices. Note: Internal fixation devices can ultimately compromise the bone’s strength, and intramedullary nails and rods or plates may be removed at a future date.

Discuss dietary needs.

Rationale: A low-fat diet with adequate quality protein and rich in calcium promotes healing and general well-being.

Discuss individual drug regimen as appropriate.

Rationale: Proper use of pain medication and antiplatelet agents can reduce risk of complications. Long-term use of alendronate (Fosamax) may reduce risk of stress fractures. Note: Fosamax should be taken on an empty stomach with plain water because absorption of drug may be altered by food and some medications (antacids, calcium supplements).

Reinforce methods of mobility and ambulation as instructed by physical therapist when indicated.

Rationale: Most fractures require casts, splints, or braces during the healing process. Further damage and delay in healing could occur secondary to improper use of ambulatory devices.

Suggest use of a backpack.

Rationale: Provides place to carry necessary articles and leaves hands free to manipulate crutches; may prevent undue muscle fatigue when one arm is casted.

List activities patient can perform independently and those that require assistance.

Rationale: Organizes activities around need and who is available to provide help.

Identify available community services (rehabilitation teams, home nursing or homemaker services).

Rationale: Fracture healing may take as long as a year for completion, and patient cooperation with the medical regimen facilitates proper union of bone. Physical therapy (PT) or occupational therapy (OT) may be indicated for exercises to maintain and strengthen muscles and improve function. Additional modalities such as low-intensity ultrasound may be used to stimulate healing of lower-forearm or lower-leg fractures.

Review proper pin and wound care.

Rationale: Reduces risk of bone or tissue trauma and infection, which can progress to osteomyelitis.

Rationale: Prompt intervention may reduce severity of complications such as infection or impaired circulation. Note: Some darkening of the skin (vascular congestion) may occur normally when walking on the casted extremity or using casted arm; however, this should resolve with rest and elevation.

Demonstrate use of plastic bags to cover plaster cast during wet weather or while bathing. Clean soiled cast with a slightly dampened cloth and some scouring powder.

Rationale: Protects from moisture, which softens the plaster and weakens the cast. Note: Fiberglass casts are being used more frequently because they are not affected by moisture. In addition, their light weight may enhance patient participation in desired activities.

Emphasize importance of not adjusting clamps and nuts of external fixator.

Inform patient that the skin under the cast is commonly mottled and covered with scales or crusts of dead skin;

Rationale: It will be several weeks before normal appearance returns.

Wash the skin gently with soap, povidone-iodine (Betadine), or pHisoDerm, and water. Lubricate with a protective emollient;

Rationale: New skin is extremely tender because it has been protected beneath a cast.

Inform patient that muscles may appear flabby and atrophied (less muscle mass). Recommend supporting the joint above and below the affected part and the use of mobility aids (elastic bandages, splints, braces, crutches, walkers, or canes).

Rationale: Muscle strength will be reduced and new or different aches and pains may occur for awhile secondary to loss of support.

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